Case Study 1

Cognitive Behaviour Therapy
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Case Study 1

Debbie Featherstone |
I have many really interesting cases of people coming to me for help with tinnitus, the most interesting being really quite complex where tinnitus isn’t the only problem they are trying to cope with.

One such case is a lovely chap - let’s call him “Len” for the purposes of this case.

Len was first referred to me via a solicitor. He had been getting in to a lot of trouble with the local council because of a noise “war” being waged between him and his next door neighbour, and he was being accused of breaching a second noise abatement notice. Not only was he being accused of this, but there was an impending court case (criminal court) with a real possibility of a jail sentence!

Issues around all this had been ongoing for over 8 years! Len was coming up to his 70th year, and had been put through the wringer including there having been a mistaken diagnosis of “musical hallucinations”, being coerced in to taking antipsychotic meds, and vilified in a psychiatric report because he stopped taking them (they made him feel ill) because according to the prescribing psychiatrist the meds reduced the “musical hallucinations”. He was also bullied by officers from environmental health during interviews that were conducted in a police station. Transcripts of those interviews clearly demonstrated bullying.

Arrangements were made via the solicitor for Len to be brought to my clinic for a full assessment, including an audiological assessment. Hundreds of pages of records including transcripts of interviews accompanied the referral.

My role was as Expert Witness to the Court on behalf of the defendant, ‘Len’. Prior to the pre-court hearing, I asked Len’s solicitor what were the chances of the charges being dropped to which she replied, "highly unlikely" as the council were determined to have him removed from his home. This would make Len homeless.

I was shocked. I hadn’t realised there was any way that a council responsible for homing could also render people homeless!

There was very little notice given to fit in the assessment and produce a full court report, as the solicitor had great difficulty finding anyone who could act as an Expert Witness to the Court. I completed my report and submitted it 2 days before the court hearing, one day before the pre-court hearing. The prosecution dropped the case at the pre-court hearing after reading my report, so Len was spared the court and possible jail, and no doubt hundreds if not thousands of pounds were saved in court costs.

This did not resolve the longer term situation for Len, the neighbour or the council though. Nothing practical was offered to Len (or the neighbour) to help work through these difficult issues; on the contrary, I found out through a chance meeting some months later with an audiologist who knew Len, that the whole scenario of a further noise abatement notice was imminent.

Following the prosecution dropping the case, although I had asked the solicitor to inform Len if he would like to attend my clinic for help that I would happily provide it, it turned out that Len had not been made aware of this. So, now some months later on, the audiologist passed this information on to Len, and arrangements were subsequently made for him to be brought along to the clinic again. In addition to the presenting hearing and tinnitus related issues, Len is not in the best of health and his mobility isn’t good. Public transport is not therefore possible for him, and he can walk no distance without being in pain.

Although I was offering to work pro-bono to help Len, the council refused to fund transport for him to attend and even withdrew the little support he had of a council Intervention Officer.

It was then that I sent a strongly worded letter to the council in what I suspected would be a futile attempt to have the council fund taxi transport to bring Len to appointments, the local Audiology department copied in to also receive the letter.

To my surprise, after several weeks, the council agreed!

At the time of writing this, I am part way through my work with Len. With some now 10 years of ingrained belief that his neighbour has been taunting him by playing loud music and turning the volume of her TV up to deliberately provoke him, and the belief that the council representatives have that Len is a troublemaker, is this situation resolvable?

To my mind, both Len and his neighbour have been let down by the “authorities”. The situation has been escalated to such a point that there can be no “winner”! My work with Len is ongoing, and one factor has changed just this week. That is that the council has agreed to move Len’s neighbour, although how long that might take is an unknown.

This situation is an on-going one, and Len is slowly coming around to the idea that the "music he hears from next door" - that when (during his initial assessment) I asked what EXACTLY is it that you are hearing, Len replied "it sounds like boom-boom-boom". He had (understandably in my opinion) interpreted that noise as being the base sounds of music playing.

There had been occasions - many of them over the years - when Len had become so angered by the "noise made by his neighbour" (that the neighbour denied making) that he "upped the ante" and turned his music or TV up louder and/or banged on the partitioning wall shouting at the neighbour to shut up!

Len had, in fact, made every effort to help his situation. He had used headphones for years to a) try to help block out the noise from next door and b) to listen to his own music or TV at a low volume. Again understandably from my point of view, the headphones did not block out the noise from next door! It wouldn't do so of course, if the noise was in fact being produced "internally" as tinnitus is, whatever the cause or type of tinnitus it might be.

He describes in addition to the intermittent "boom-boom-boom" noise a constant "sizzling" noise that he does - and did - accept as being "tinnitus". Unfortunately, when he was seen by psychiatry, he was labelled by them as having "musical hallucinations" - rather than tinnitus.

To further complicate the issues around this, Len has severe hyperacusis. This means that even when he does turn up his own music or TV, he can only bear the intensity for very short periods of time because of the pain it causes him. His high arousal state (when becoming angered) would enable him to cope maybe for a few minutes longer than when he was calm. However, all the years of animosity between he and the neighbour, PLUS the council's attitude toward him and their repeated threats of noise abatement notices, are not exactly condusive with feelings of calm.

There is a further 'complication' for Len, and that is he has high frequency hearing loss and (unusually and particularly so at his age) exceptionally acute hearing in the low and mid-frequencies.

Put together, Len's complex symptoms could very likely be attributable to TTTS (Tonic Tensor Tympani Syndrome). A major maintaining factor - if not a cause - of TTTS is anxiety.

There are additional factors that have also not been taken account of. We don't know the hearing levels of the *elderly neighbour (*described by council); so this brings in the possibility of hearing loss - which could well mean the neighbour does play music and has TV volume higher than for ‘normal’ hearing levels. With Len's acute hearing in the low and mid-frequencies, he more than likely IS hearing the neighbours music and TV on occasions.

This week, I have given him some record sheets to fill in. Date, time, what noise he hears, and record what the noise is like when he moves to another room - the same or quieter. He practiced this as an experiment last week, and told me at this week's appointment that the noise is often quieter when he moves to another room (or goes outside as he often does). This of course is an indicator that the noise he is hearing is an EXTERNAL noise. When the noise is still the same when he moves to another room, that is his own "noise". My hope is that this exercise will give Len a clear indication of when noise is his own boom-boom-boom, and when it is being made externally. Depending on the records of course, there may be some "evidence" - if it is there at all - that Len's neighbour is contributing to the issue. And I must say, I would be most surprised if it is not the case on occasions.

The psychology of this situation - for all parties including council - is set within the context of long term stress for all concerned.

I recall from my very early days in Hearing Therapy where we were told the story of a fictitious individual living in a mid-terraced hourse. There were neighbours both sides. You get on well with the neighbours one side of you (we'll call them Neighbour A) and don't get on with those the other side (Neighbour B).

Neighbour A has building work done in their house. There is a lot of noise: banging, drilling, scraping, thudding etc etc. On occasions, it becomes so noisy, you decide to go out for some respite, but you look forward to when the work is finished, and when it is, you pop round to their house to see the finished work.

Neighbour B has building work done in their house. There is a lot of noise: banging, drilling, scraping, thudding etc etc. You become angrier and angrier; the noise is unbearable and the dislike you already had for Neighbour B grows in intensity. You become so stressed by it all, you have headaches, feel ill and feel trapped. It seems to go on for ever!

In fact, we were told of this story by Mr Jonathan Hazell - at the time and for many more years to come - a leading expert in tinnitus and its management. Even our updated understanding and management strategies for tinnitus still has its foundation in the work he did along with Dr Pawel Jastreboff. Jonathan Hazell wasn't actually talking about noisy neighbours. He was talking about the "significance of sound", and how we react to "tinnitus" depending on what meaning it has to us.

I'm not sure how Len's situation is going to finally turn out, but I did ask him a couple of weeks ago if he feels he is getting anything out of coming along for these sessions. "Oh yes!" he said and went on to explain what he had found helpful. I just hope that this whole situation can be resolved sooner rather than later. It won't "go away" when the neighbour moves out because next door will soon have someone new in there. But finally, Len feels as though he is being listened to and he is starting to understand what is going on. As this is an on-going case, if/when there is anything new to report on this case study, I will update in due course.


Debbie Featherstone MSc Hearing Therapy | Psychotherapy & CBT Specialist

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